Recently, on consecutive days, National Public Radio ran segments about declining enrollment at universities.

And today, the president of a state university 60 miles from me (without an optometry school) noted, for the first time, a decline in his entering freshman class sizes while the president of the state university nearest me (with an optometry school) had maintained entering freshman enrollment by changing entrance requirements.

This website has, for ten years, been a critic of the many new optometry schools that have opened and the almost doubling of optometry school graduates that has produced a decline in numbers of “qualified” applicants per optometry school seats. The ratio of “qualified”, non-duplicate applications now flirts with one per seat. The universities creating those new optometry schools justified them by citing “inflated” federal reports (based upon optometry provided estimates) claiming more optometrists were needed, and that new optometry school would provide “jobs” or provide eye care to underserved areas. However, the number of optometrists per capita had already been climbing for some time and there is ample evidence increasing optometry graduates does not proportionally increase the numbers practicing in underserved areas unless given monetary incentives such as student load abatements for practicing there. In the absence of incentives graduates will continue to open practices in urban areas rather than poverty stricken rural areas.

It is also well known that the numbers entering universities tend to rise in economic recessions and to decline in good times and that optometry school applicants rise and fall proportionally with university enrollments. Our Nation, since the end of the Korean War, has gone from about 20% of high school graduates attending a university to over 60%.

It is therefore concerning that while the numbers of optometry graduates has almost doubled (and another new school is proposed) the ratio of qualified applicants to seats has seriously declined and the country is overdue for a recession from being in the longest “bull market” to exist on Wall Street.

Nor is it reassuring that a recent independent study found that optometry school graduates have the highest ratio of student debt to projected earnings of any health profession (medical school graduates have one-half the debt to earnings ratio facing optometry graduates).

And, at last count the total national student debt held by current and former university students was over 1.4 trillion dollars, larger than all the credit card debt held by the entire US population.

Meanwhile, for the last 15 years, the numbers of medical and dental students have remained almost constant while the number of podiatric students has declined.

Nor is it realistic to think this Nation could afford to repay all outstanding student loan debt or to “wave a wand” and forgive all student debt.

For all these reasons I believe some optometry schools should plan how to survive in the future by reducing their class size.

For an unacceptable response would be to reduce entrance requirements and put less qualified students in those seats.

And it is possible that some optometry schools may have to either close or water down their entrance standards which will damage our profession and patients.

This may be why one of the newer schools posting faculty recruitment ads specify they are non-tenure track.

Editor

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After posting the above, a colleague sent this link to me.

The Higher Education Apocalypse

Editor

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In his article “Medical education needs to stop burning out students — now,” Augustine Choi suggests the culture of medical education is responsible for increasing rates of depression and burnout among medical students, and suggests that more programs are needed to address self-care and wellness in order to build resilience…

Read the full article here: To extinguish burnout, bring back physician autonomy

Editor

The most divisive issue in optometry continues to be whether general practice optometrists should take additional CE hours “above” those required for license renewals and then pass additional periodic examinations “beyond” the multiple NBEO examinations they had to pass for graduation and initial licensing in order to become “board certified” by the American Board of Optometry (ABO).

The ABO believes optometrists should go “above and beyond” what it calls the “minimum” standards and training required for graduation, licensing and then license renewals and seek to become “board certified” by ABO. See Note 1.

The ABO credential is not required by any state licensing board or health/vision plan. Since ABO does not require residency training in a specialty or passage of a specialist examination it is also not a specialty board.

ABO refuses to recognize that medicine, osteopathy, dentistry, and podiatry only award “board certification” to those who complete specialty residency training and pass specialty examinations after licensing.

And to support ABO the AOA will close, next year, its annual Optometric Recognition Award, established in 1975 and given by the AOA President each year to AOA members completing more CE hours than required for license renewal.

The ABO remains criticized by many because:

• All other Medicare physician groups offer board certifications only to residency-trained specialists within their professions. Optometry is a profession and not a specialty of a profession.
• ABO continues to imply its certification will become required by health plans which has not, and will not happen due to restraint of trade statues.
• ABO suggests those it certifies will be seen by the public as being “above” other optometrists which pits optometrists against each other.
• No optometry, medical, dental, osteopathic or podiatry state licensing boards require board certification though all those professions have board certified specialties.
• By established (settled) law, the requirements to practice optometry remain a professional degree and a state license and the power to regulate optometry is reserved by the states and not the federal government.

Still, ABO continues to try to blur the line between its “substitute board certification” and real specialty board certification by now offering a reduced fee of $500 rather than $950, to residents and new graduates if they take the ABO examinations within 10 years of graduation.

Residents training in medical optometry should understand:

1. ABCMO is a specialty board that requires passage of the Advanced Competence in Medical Optometry examination offered by NBEO after completing an accredited medical optometry residency.
2. Only ABCMO board certification is accepted and required for appointment as a specialist in medical optometry at health facilities accredited by the Joint Commission. See Note 2.

Although optometry residencies only began in 1975, today 30% of graduates enter into residency training in a specialty.

Those serving residencies in specialties without a certifying body will eventually set up specialty boards to certify them.

In addition there are learned societies they can join now (Optometric Glaucoma Society, Optometric Retinal Society) and low vision, blind rehabilitation and visual training groups and the Diplomate program at the American Academy of Optometry and special interest groups

Notes

1. No data was ever presented by those creating ABO to show there was a need for additional training and testing of licensed optometrists in general practice and optometry malpractice insurance rates remain remarkably low. In addition to the costs and time required to become ABO certification, costs and time are required to attend courses and take exams to “maintain” ABO certification. These programs are called Maintenance of Certification (MOC).

2. The Joint Commission is the Gold Standard for accreditation. It inspects and accredits over 21,000 US health care programs. The credentialing committees required at Joint Commission accredited facilities recognize and accept ABCMO board certification.

The Joint Commission is also known by its previous names, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Joint Commission on Accreditation of Hospitals (JCAH).

This question recently came to mind while noticing my dentist’s board certification in oral surgery hanging next to his D.D.S diploma and State License.

You probably also have your ABCMO board certification on the wall with your State License and O.D. diploma. But, if you are on the medical staff of an accredited health facility you must do more.

Your Credentialing Committee needs to know you served a medical optometry residency, passed a written examination, and met additional requirements for ABCMO certification because it recommends all medical staff appointments, clinical privileges, and is part of the advancement and promotion process.

Credentialing Committees are required to contact ABCMO every two years to verify your board certification (VOC).

Some optometrists at medical facilities may have not yet notified their Credentialing Committee of their certification or updated their official personnel file (OPF) to include board certification.

Failing to do this is unwise as Credentialing Committees evaluate and determine their privileges, evaluations and promotions.

For example, at VA health facilities, Form SF 171 must contain your specialty, name of specialty, residency program and specialty board address because their Credentialing Committees forward this information to the Central Office committee that processes all optometrist appointments, promotions and advancements.

Be sure your personnel folder at your facility is up-to-date because Credentialing Committees are required to verify board certification by checking directly with ABCMO every two years and not by inspecting the documents on your office wall.

Off the Cuff: Students, Debt and the Future of Optometry was written by Arthur B. Epstein, OD, FAAO and Chief Medical Editor of Optometric Physician.

Part 1 – Off the Cuff: Students, Debt and the Future of Optometry

Student debt is a steadily escalating problem for health care professionals. It has gotten so bad that this past week, the NYU School of Medicine announced that it is waving tuition for all new and existing medical school students. Their action is in response to growing debt among young doctors and the trend away from lower-paying, but much-needed, primary care practice. The school reportedly views this as a public health issue. The hope is that other medical schools will follow suit.

Unfortunately, optometry doesn’t appear that fortunate or farsighted. To my knowledge, no optometric program is planning to wave tuition or even reduce it to more affordable levels. In sad fact, optometry school graduates have a higher debt-to-income ratio than any other health care professionals with an earning capability far lower than most. With even more new schools on the already crowded horizon, it’s difficult to not view additional optometry programs as predatory, preying on increasingly less-qualified students who have dreams of becoming a doctor.

For many of these young ODs, I fear that their dreams may quickly turn into a nightmare. The glut of new graduates will eventually exceed demand, if it hasn’t already. With continuing advances in technology and too many practices still mired in traditional refractive care, OD salaries are likely to tank while competition for a shrinking number of positions grows exponentially. More and more of these young ODs will be working just to pay off their student loans, and some may not be able to pay them off at all. If reimbursements drop to fuel Medicare for all, it won’t be pretty for any of us, but especially painful for young and in-debt grads.

Unfortunately, there is no simple answer. By the time the law of supply and demand kicks in, it will be too late. Some have suggested that we actively discourage prospective new ODs from pursuing optometry as a career. The only thing that will accomplish is to deprive the profession of a greater number of quality candidates rather than dissuade the poor ones.

Eventually, some existing schools will have to close and new ones not open, but that will never happen as long as there are students willing to pay, and schools are making money from minting new ODs. The one solution that would work and might actually save the profession is the hardest. Raise entry and training standards to almost painful levels. That would ensure qualified candidates and well-prepared ODs, and force the worst schools to close. Ultimately, the future of optometry lies in the hands of the AOA and its Accreditation Council on Optometric Education.

Subscribe to the Optometric Physician e-Newsletter (scroll down to “Reviews Group”)

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Off the Cuff: The Big Bang was written by Arthur B. Epstein, OD, FAAO and Chief Medical Editor of Optometric Physician.

Part 2 – Off the Cuff: The Big Bang

Over the past few months I’ve written extensively about my concerns for the future of our profession. This is an emotional issue and, as you might expect, has generated a good deal of comment. In fact, no topic has ever generated more email with the exception of the very divisive topic of board certification—or what we call board certification.

From colleagues across the country, the general consensus—with virtually no dissent—has been that we have too many schools, too many graduates and a profession that, if it doesn’t right itself will soon, be in serious trouble. Rarely have I seen so many on the same page on a single issue. Unsurprisingly, some in academia don’t see these concerns in the same way and have taken my comments as personal attacks on their institutions or have convinced themselves that I have declared a holy war on optometric education. Nothing could be further from the truth.

Here is the truth as I see it. Every academic institution has an inviolable duty to serve the public good by producing qualified, knowledgeable and skilled graduates. This starts with the admission process where entering students must be selected that can be molded into capable clinicians and successful practitioners. Our institutions have an obligation to the profession at large to responsibly plan for the needs of the public and ensure that its graduates can achieve professional success and financial independence. Ideally, this process should be self-regulating, as it has historically been in other professions. Organizations such as ASCO, the AOA and the ACOE should approach with balance and transparency and discourage new and existing programs that fail to meet the needs of the public and the profession. The most recent ASCO/AOA optometric manpower study and its subsequent spin was neither balanced nor transparent.

Let me make it clear that I don’t think the problem is our new schools. The problem is too many schools. I recently visited Midwestern University Arizona College of Optometry, and I was honestly blown away by how the program has evolved and grown since its inception. Likewise, I have visited older programs that are excellent. Truth be told, some newer and some older programs have not kept up, and their continued existence should be in question. Common sense planning suggests that we clearly don’t need more than one program serving a single city or state unless there are truly extenuating circumstances.

Our organizations must take strong charge of controlling our profession’s future. That control starts with the number and quality of our educational programs. However, we all must have a voice in this. I am asking you to complete this simple open questionnaire about your perceptions regarding optometric education, the number of programs we have and need and of the quality of current optometric education. Let your voice be heard.

Link to Questionnaire

Subscribe to the Optometric Physician e-Newsletter (scroll down to “Reviews Group”)

This is an abridged version of the author’s paper distributed after an invited talk to the study body of the Illinois College of Optometry in Chicago, Illinois in 1998. Notes were added August 2018.

Introduction and Purpose

There are few accurate studies of how optometrists practice. And no studies cited in the literature have been made by physically visiting practice sites to gather practice data first-hand.

The only comprehensive study, the 2012 Lewin National Eye Care Workforce Survey of Optometrists, did collect detailed data on types of practices using a mail survey in which optometrists were asked, among many other questions, which of 17 specific practice types listed on the survey response sheets best described how they practiced.

For undisclosed reasons, Lewin collected this data but did not publish it. Instead of reporting the percentages of optometrists in each of the 17 practice types, Lewin reported only whether responding optometrists were self-employed [70%] or employed-by-others [30%].

By reducing the survey’s 17 possible practice types to only two types, whether the optometrist was, or was not, employed by others, severely limited information about how the surveyed optometrists actually practiced as it left out the other 15 different types of practice.

In 1998 the Author spent two weeks visiting all the optometry practices he could locate in the Akron, Ohio metropolitan area via the Akron Ameritech Yellow Pages, the membership list of the Ohio Optometric Association and membership list of the American Academy of Optometry. He visited these 72 optometry practices on site and identified 91 licensed optometrists who practiced at one or more of 72 practices. These 91 optometrists included several not listed in any membership list or the phone book who resided outside the Akron metropolitan area.

While at the practice site the author took pictures showing the location and surroundings of the practice for later determination as to whether the practice appeared to market itself as an office–based or store-based practice. While such determination is somewhat subjective, those who assisted the author in picking which marketing method was used by each of the 72 practices were seldom in disagreement but, when reasonable doubt existed the practice was classed as office-based rather than store-based.

Summary of Results

Sample Size

• 72 practice sites and 91 optometrists distributed among them with 28 practicing at more than one site.
• On average, 72% of optometrists based at offices were AOA members compared to 33% at stores with AOA membership for all 91 optometrists averaging at 55%.
• Two of the 91 optometrists were Fellows of the American Academy of Optometry (2%) and they were both office-based.

Ownership of Practice Sites

• 35 commercial-owned optical stores
• 27 optometrist-owned offices
•  7 optometrist-owned stores
•  3 ophthalmology offices

Optometrist’s Primary Practice Site

• 52 practiced only, or mainly, at optometrist-owned stores
• 34 practiced only, or mainly, at optometrist-owned offices
•  5 practiced only at ophthalmology offices

Examination Fees

• $25-$43 at store sites
• $50-$72 at office sites

Optometrist dilated asymptomatic new patients?

• Routinely; 31% usually O.D.s at offices
• Sometimes; 31% a mix of offices and stores
• Never; 39% usually O.D.s at stores

Of the 91 optometrists, 26 (29%) were not listed in the Akron Ameritech Yellow Pages and did not have home addresses in the metropolitan area. Of these 26, 16 practiced at commercial stores.

In summary, in 1998, about half of practices were optometrist owned; the majority of optometrists practiced at stores, and about one-half of optometrists did not dilate eyes performing general eye examinations.

Optometrists practicing in office-type settings were more likely to dilate their patients, be AOA or AAO members, charge higher fees, schedule by appointments vs. walk-ins, and be located in the suburbs of Akron.

One striking fact however stood out to the author (licensed in 1974) when the practice model held out to our generation was the “professional practice” located within an office building containing other professionals and located above street level.

Only two practices among the 72 visited met those 1974 requirements. And while one of these two was vibrant with patients in its waiting room, the other practice had a hand written sign at its door indicating the phone number to call for an appointment and was located in an old two-story building up a creaky, musty staircase.

Survey Methods

The survey was designed to visit all 72 locations in the Akron metropolitan area found to have practicing optometrists and to determine ownership of each location, names of optometrists working full or part time at that location, costs of eye examinations, whether dilated exams of new patients were made and the overall style of the practice as to its orientation towards a private office or a store atmosphere. AOA and AAO membership or fellowship was determined by waiting room observation, asking questions and/or consulting membership lists of the Ohio Optometric Association and the AAO listings of Fellows. Desk personnel were asked about available appointments and whether a new patient would be dilated. Photographs were taken for later use to determine whether the site appeared as an office or store. Sample photos are in the appendix.

Examinations were not obtained so quality of examinations and materials were not determined. The chief purpose of the survey therefore was to determine types of practices in which optometrists practiced and the ownership of those practices to differentiate between what are commonly called “private practices” and “store practices”; terms that do not have precise meanings and can be misleading so a classification system was used that spanned 18 distinctively different types of practices.

Initial locations of practice sites were determined by using the 1998 Akron Ameritech Yellow Pages but, during the survey, 26 additional, unlisted optometrists and 3 additional locations were identified.

Types of Practice and % of Each Practice Type

Locations Owned by Optometrist(s)

Office-Based Practice

1. Solo office in professional office building    5.6%
2. Office, 2 or more optometrists in professional building    2.8%
3. Solo office in professional mall or plaza    6.9%
4. Office, 2 or more optometrists in professional mall    5.6%
5. Solo office in dedicated free-standing building    5.6%
6. Office, 2 or more optometrists in free-standing building    1.4%
7. Solo office in commercial mall or commercial setting    6.9%
8. Office, 2 or more optometrists, commercial mall    2.8%

Store-Based Practice

9. Solo store in dedicated free-standing building    1.4%
10. Solo store in commercial mall or zone    2.8%
11. 2 or more optometrists in free-standing store building    1.4%
12. 2 or more optometrists in mall or commercial setting    4.2%

Locations Not Owned by Optometrist(s)

Store-Based Practice

13. Co-op optical stores, a local cooperative    5.4%
14. Union Eye Care stores, local optical cooperative    4.3%
15. Mall Optical stores (Lenscrafters, EyeMasters, Pearle, etc.)    16.7%
16. Department Store optical stores (Sears, Penny, Ward, etc.)    8.3%
17. Local optical/optician stores    13.9%

Office-Based Practice

18. Free-standing ophthalmology group practice    4.2%

With these 18 types of practice settings it was possible to enumerate all practice types at the 72 locations in the Akron metropolitan area at which optometrists practiced.

While perhaps appearing overly detailed, this complexity came from the widely diverse types of settings at which the 91 optometrists practiced. Only this level of detail can avoid ambiguity as to optometrists’ practice types and show the wide variety and compartmentalized ways in which optometrists practice.

Which is why studies using less precise typing of sites can offer little substantive data. For example, studies using only two or three vague terms such as “self-employed”, “employed”, “private practice”, to represent the 18 types of practices are misleading and imprecise.

The 91 optometrists distributed across these 18 types of practices resulted in:

• 47.2% of optometrists practiced in an optometry owned location of which 37.5% were offices and 9.7% stores.
• 48.6% of optometrists practiced in a commercial optical store.
• 4.2% of optometrists practiced in an ophthalmology office.

The most frequently encounter location types were:

• Mall chain optical store    12
• Local optician/optical store    10
• Office in office mall    9
• Office in commercial area    7
• Co-op/Union optical store    7
• Dept. store optical    6
• Office in office building    6
• Office in dedicated building    5
• Store in commercial area    5
• Ophthalmology office building    3
• Dedicated store building    2

Office or Store Optometrist?

While it was relatively simple to determine whether a location was an optometry office or optometry store, it was more difficult to decide if an optometrist was office or store based since a good number of optometrists practiced at 2 or more locations.

For while most optometrists located at offices did not practice at stores, a few spent 1 day/week at a commercial store location and it was common for store optometrists to practice at several stores and even different corporate stores. As one example, the optometrist who practiced at a Wards Optical Department, a Wal*Mart Vision Center, an optician’s store and an optometrist’s office.

• Including ophthalmology offices, 42.9% of optometrists practiced primarily at offices.
• The majority of optometrists, 57% practiced in a store location owned by an optometrist or non-optometrist.
• Locations at which optometrists practiced were almost equally divided between offices and stores owned by optometrists (47%) and stores owned by non-optometrists (48.6%) with the remaining 4.2% at ophthalmology offices.
• Of the 91 optometrists 26 (29%) were not listed within the Yellow Page listings and 16 of these were based at commercial mall optical stores.

Yellow Pages Marketing

Optometrists marketed in Yellow Pages under:

• “Optometrists-Doctor of Optometry (OD)”    62%
• Within ad in “Optical Goods”    26%
• Under “Optical Goods”    8%
• Somewhere within Yellow Pages    71%
• No listing*    29%

*16% of these were at stores rather than offices.

Author’s Notes

In 1998 the author stated there were about 31,000 U.S. licensed optometrists and about 22,717 dues paying AOA members for a national 73% AOA membership rate.

In 2018 there are about 43,000 licensed optometrists and about 20,600 dues paying AOA members for a national 48% AOA membership rate.

To the degree these numbers are accurate, it seems quite possible that since this survey (and others) found a lower (37%) AOA membership among commercial optical store O.D.s compared to a 69% rate among optometry-owned offices-stores, that the decline in national AOA membership from about 73% to 48% may be due to the relative increase in commercial-store-based optometrists, the rapid increase in optometry schools and graduation rates and the shift of optometrists from privately owned practices and stores to essentially “piece rate” or “hourly” corporate employees.

Such a major shift has now taken place among pharmacists who, historically, owned their own pharmacies but today 80% are employed by the five largest national pharmacy store chains.

Sensing this change in how optometrists practice led the author to title this survey, in 1998. “The Mitosis of Optometry” for, as the data from 1998 show, by that time, the way optometrists practiced had already become highly fragmented.

Debate over the findings of the two Lewin Studies issued in 2014 has chiefly centered on Lewin’s prediction of an “adequate supply” of “eye doctors” in its Eye Care Workforce Study: Supply and Demand Projections. The second study, the Lewin National Survey of Optometrists however generated little discussion or comment.

But there was useful information in the Lewin National Survey of Optometrists of such wide scope and sufficient detail to offer accurate insight into how optometrists practiced and viewed their income.

However, for reasons unknown, Lewin choose not to release, but instead obscure, survey findings concerning the types of practices optometrists operated and their degree of dissatisfaction with income while reporting fully the other survey results. Why, one might ask?

The Lewin national survey of optometrists was mailed in 2012 to nearly 4,000 optometrists randomly sampled from 39,580 actively practicing optometrists from whom 726 responses were received. Lewin stated this sample size produced an expected confidence interval above 95% with a margin of error below 5%.

Responding optometrists making up the survey sample were, on average:

    1. 60% male and 40% female
    2. 62% between the ages of 40-65
    3. Race/Ethnicity   
           White   86.0%
           Asian    8.0%
           Black    1.4%

Selected pertinent findings of the Lewin National Survey of Optometrists follow.

Notes of Caution

1. Lewin did not publish all data it collected. Its survey findings of which of 19 types of practice settings optometrists believed best described their practice was collected but not published. Instead, Lewin only reported two types, the numbers of “self employed” and “employed by others” practices. Failure to report the number practicing at each of the other 17 types of practice settings obscured the degree to which optometry practices have shifted from “private” to “store” settings. (Survey questions #6a and #6b)
2. Lewin’s “satisfaction survey” was difficult to assess due to its 6 possible response “bubbles” of which only the end ones were labeled (extremely satisfied, extremely unsatisfied) with no middle bubble to signal satisfied. (Survey question #21)

Survey questions #6a, #6b and #21 are shown in detail below.

The National Survey Findings

Survey Question #21

Percentage Satisfied or Extremely Satisfied with:

Scope of Practice/Autonomy          62%
Geographical Location               61%
Job Security                        60%
Career Options/Professional Growth  56%
Inclusion in Medical Plans          36%
New Care Delivery Models            29%
Income/Reimbursement                17%

Lewin states this survey question showed 64% of responding optometrists not satisfied with access to medical plans, 71% not satisfied with new care delivery models and 83% not satisfied with income/reimbursement.

Question #21 contained 6 circles for respondents to indicate varying levels of satisfaction with their income, with “Extremely Satisfied” at the left and “Extremely Unsatisfied” at the right.

     Extremely                         Extremely
     Satisfied                         Unsatisfied
        O      O      O      O      O      O

But the 4 in-between circles were not labeled so it was not clear to responding optometrists what they represented, especially without a “middle circle” to presumably indicate satisfaction. Lewin stated, however, in its summary of findings that “Only 17% of respondents reported that they were satisfied with their income or reimbursement.” So, among the 83% not satisfied with their income there had to be some who were extremely or somewhat unsatisfied or whatever the 4 unlabeled bubbles were supposed to represent.

To be more precise, Lewin should have labeled and reported the percentages for each of the 6 bubbles to show the degrees to which optometrists were unsatisfied with their income rather than stating 83% were unsatisfied.

There is an important difference between finding 83% were not satisfied with their income and a finding that 83% were extremely less than satisfied. All we can deduce from Lewin’s failure to label the circles and show their percentages is that 83% were a little, some, or extremely unsatisfied with their income while only 17% were satisfied some, a little or extremely satisfied with income.

Survey Questions #6a, #6b

Principle Practice Settings

It was good to see, both for the first time, a national survey and one asking in detail how optometrists actually practiced in situ rather than asking ambiguous questions.

Lewin asked optometrists to select which of 19 types of practice setting best described where they practiced.

A. Those stating they were “self-employed” could describe their practice as:

1. Solo owner not affiliated with regional/national (r/n) retail company
2. Owner, small group not affiliated with r/n retail company
3. Owner, large group not affiliated with r/n retail company
4. Solo franchise, affiliated, adjacent to or within a r/n retail company
5. Group franchise, affiliated, adjacent to or within a r/n retail company
6. Independent contractor/lessee
7. Other (specify)

B. Those stating they were “employed by others” could describe their practice as:

8. Employed by O.D. in private practice
9. Employed by O.D. owned franchise/affiliated with r/n company
10. Employed by non-O.D. owned independent franchise
11. Employed by ophthalmologist
12. Employed by hospital/clinic/health care facility
13. Employed by community health center
14. Employed by HMO
15. Employed by r/n optical company
16. Employed by educational institution
17. Employed by U.S. or local government
18. Employed by ophthalmic industry
19. Employed by others (specify)

But Lewin did not report the percentages of each of these 19 practice types.Instead, Lewin only reported that:

• 30% were employed by others (24% male, 40% female)
• 70% were self-employed (76% male, 69% female)
• Older practitioners trended towards self-employment (over age 65, 76% male and 60% female)

Lewin threw away the most accurate information our profession would have ever had on types of settings at which optometrists practice. Why?

Also, Lewin’s sample of just under 400 optometrists came from a combination of three sources; Provider 360, AOA membership lists, and the Provider Enumeration System. But Lewin did not indicate what percentages of its sample were AOA members or if the percentage of AOA members was the same as in the general population of optometrists. That would have been important to know for AOA members practice differently than non-AOA members and only about 50% of practicing optometrists are AOA members.

Age and Gender

Age     <30    30-39   40-49   50-65    >65 
M/F     9/21   75/96   90/72   238/45   68/7 

Entering Enrollment

2011-2012 1,572

(1,800 in 2018)

Race/Ethnicity of Students

White              56.0%
Asian              30.0%
Hispanic/Latino     4.4%
Black               3.0%
Native American     0.4%
Pacific Islander    0.2%
Other               7.0%

Age and Gender Distribution of Self-Employed

At ages under 30, 29% of males were self-employed compared to 11% of females. But, after age 30, the number of self-employed males and females rose steadily until, at age 65+, females were at 100% and males were at 93%.

Age and Gender Distribution of Employed-by-Others

At ages under 30, 89% of males and 71% of females were employed by others. But, after age 30, the numbers of employed-by-others males and females steadily declined until, at age 65+, females were at 0% and males at 7%.

Total Hours of Practice per Week

The overall average was 40.7 hrs/week with very little variation from this value across age, practice type and years of experience except males averaged 42.15 hrs/week while females averaged 38.55 hrs/week.

Number of Practice Sites

Overall, 66% of optometrists practiced at just one site, 26% at two sites, 4.5% at three sites and 2.8% at four sites.

These percentages declined with age of optometrist until, by age 65+, they became 80% at one site, 20% at two sites, and 0% at three and four sites.

Weeks Worked per Year

Mean weeks worked per year was 47 with very little variation from this number across age, gender and type of practice.

Patient Visits per Week and Hour

Average weekly patient visits were 63 per week with an average of 70 for self-employed and 90 for employed by others.

Average patients per hour were 1.80 with 1.89 for male and 1.63 for female optometrists.

Survey Question #9

Excess Capacity

Optometrists were asked how many additional patient visits they could provide per week if fully booked with zero no-shows without adding additional hours, staff or equipment.

Overall, optometrists said they had, on average the capacity to see 19.8 more patients per week which Lewin termed an “excess capacity” of about 32%.

In its other report, the 2014 Eye Care Workforce Study: Supply and Demand Projections, Lewin used this “excess capacity” of optometry “chair time” to replace the shortages of future ophthalmologists it predicted by assuming optometrists provide the same care as ophthalmologists and they would replace all ophthalmology shortages. Using this highly unrealistic assumption, Lewin claimed there was no surplus of optometrists but, instead, an “adequate supply of eye doctors”; a seriously misleading characterization of the Lewin Supply and Demand Projections.

To make this claim, Lewin assumed that 1.36 optometrists provided the same services as one ophthalmologist despite state practice laws that do not permit optometrists to hold the same scopes of practice as ophthalmologists. But Lewin made this assumption so it could consider an “eye doctor” to be either one ophthalmologist or 1.36 optometrists and thereby reduce the surplus of optometrists it found by believing they would fill in for shortages of ophthalmologists.

Revenue by Source

Stand-Alone Vision Plan   27%
Traditional Insurance     17%
Self-Pay                  16%
Medicare                  15%
Medicaid/CHIP             11%
HMO                        4%
Other                     11%

Median Net Income

Overall              $113,000
Self-Employed        $113,000
Employed-by-Others   $104,000

Age       <30       30-39      40-49       50-65        65+
Male    $62,000   $113,000    $138,000    $138,000   $113,000   
Female  $87,000    $87,000    $113,000    $113,000   $100,000

Assessment

While there is much useful “secondary” information in the Lewin national survey of optometrists, the best survey to date, Lewin chose to not publish its detailed findings of how optometrists practiced or completely reveal their degrees of dissatisfaction with their incomes.

1: Questions #6a and #6b. Lewin did not release its detailed findings on the numbers of optometrists practicing at the 17 different types of practice listed in the survey. This data would have been very enlightening since there have long been debates over whether or not optometry “professionalism” has declined since the FTC removed its ban on advertising by health care providers.

It has seemed since then optometry does not wish to make public how optometrists practice. For example, prior surveys have used terms such as “private practice”, “independent practice”, “commercial practice”, “retail practice”, and “self-employed” vs. “employed” which are overlapping and imprecise practice descriptions.

Why Lewin chose to lump its 19 detailed findings into only “self-employed” vs. “employed by others” was not explained by Lewin nor explained by the two “blue ribbon” panels of AOA selected consultants advising Lewin.

For example, using Lewin’s “self-employed” and “employed-by-others” which is the more professional practice setting?

A salaried staff optometrist at the Wilmer Eye Hospital at Johns Hopkins Hospital (employed-by-others) or an optometrist owning and practicing a mall optical boutique (self-employed).

2. Question #21. This same loss of specificity befell Lewin’s summary of how “satisfied” optometrists were with various aspects of their practice.

Why were 4 of the response “bubbles” not labeled and percentages reported?

While it was clear the great majority of optometrists were “less-than-satisfied” with income, Lewin did not report what percent were “less-than-satisfied”, “somewhat satisfied” or “extremely-unsatisfied” with their income (if that is what those un-labeled bubbles meant).

Conclusions

Lewin’s two studies appear to show manipulation and “obscuring” of data involving:

1. Current and future surpluses of optometrists.
2. Increases in number of Optometry Schools and Graduates.
3. Dissatisfaction with practice incomes.
4. The Lewin Executive Summary claim of an “adequate supply of future “eye doctors”.

It has been failures to address these very issues that is causing increasing concern among practicing and academic optometrists. Being told to wait for the “facts” from the Lewin Group and its “blue ribbon” advisors has not made matters better.

So why were the facts either not addressed properly or ignored? Why did the advisory panels not object?

The two Levin reports were missed opportunities to gather pertinent and factual information important to the health of our profession and our patients.

Independent Study finds Optometry graduates face highest school debt burden.

One unfortunate result of the current oversupply of Optometrists is the reduction of income relative to student debt. In other words, Optometrists pay a higher percentage of their income to retire student loans than all the other major professions. In fact, Optometry pays almost twice the percentage as Medicine.

More Information

• Which Graduate Degrees Deliver More Debt than Income? – This is the original article and source of the graphic above.
• Degrees of Debt: Which Graduate Degrees Saddle Students with the Most Debt Relative to Income – This is a summary of the original article.
• 5 Graduate Degrees that Trigger the Worst Student Loan Payments – This is a summary of the original article with the addition of a video about student loans.
• The Optometry Surplus – A Review and Editorial
  

The Tragedy

The tragedy of the commons is a term used in social science to describe a situation in a shared-resource system where individual users acting independently according to their own self-interest behave contrary to the common good of all users by depleting or spoiling that resource through their collective action. [Source: Wikipedia]